0:00

This is a 64-year-old patient with myelodysplastic

0:04

syndrome who resided in a nursing home

0:07

and was found in the morning on the floor.

0:11

Scrolling the CT scan,

0:14

one can see that there is displacement from the midline

0:20

at the level of the septum pellucidum.

0:23

We'll measure once again.

0:25

You'll notice that when I measure from the midline,

0:29

I'm going from the falxian attachment to the bone spicule,

0:33

anteriorly, to the bone spicule of the occipital bone,

0:38

posteriorly, and that is how I define the midline.

0:41

And then, the septum pellucidum seen between the frontal

0:44

horns of the lateral ventricle to that line,

0:48

measures 11 mm or 1.09 cm.

0:52

Fool me once, shame on you.

0:55

Fool me twice, shame on me.

0:57

As you can see more clearly in this example,

1:00

the white matter of the juxtacortical white matter

1:03

does not go all the way out to the periphery,

1:06

and therefore,

1:07

this is yet another example of an isodense subdural hematoma.

1:12

Let me draw the cortical margin for you.

1:17

Here you can see the edge of the cortex.

1:20

You'll also note that further anteriorly,

1:23

we convert from an isodense subdural

1:26

to a hyperdense subdural hematoma.

1:31

This suggests that the patient has had

1:33

multiple episodes of bleeding,

1:36

including one more anteriorly that is more acute.

1:42

In addition,

1:44

you can see that the patient has blood products

1:47

that are acute along the falx.

1:51

Now, just to reiterate,

1:53

how do we know that this is an isodense subdural

1:56

hematoma and not an isodense epidural hematoma?

2:01

Remember,

2:02

crescentic shape and crossing sutures,

2:08

in this case,

2:09

the expected location of the coronal suture would

2:13

identify this as a subdural collection.

2:17

Scrolling further superiorly,

2:19

you can see the mixed density collection anteriorly

2:24

and the isodense portion more posteriorly.

2:28

For those of you with relatively good eyes,

2:31

you probably have already identified the contralateral

2:36

isodense subdural hematoma.

2:38

Here again,

2:40

we have the white matter that is not going all

2:42

the way out to the periphery.

2:45

And therefore,

2:46

there is indeed another isodense subdural

2:50

collection on the contralateral side,

2:55

in the left frontal and parietal region.

3:00

This becomes less dense posteriorly,

3:03

and again, makes the assumption that the patient

3:07

has likely had multiple episodes of head trauma,

3:11

leading to different age blood products in the subdural space.

3:17

This patient,

3:19

by virtue of the size of the subdural hematoma

3:22

and of the degree of midline shift,

3:26

would undergo neurosurgical evacuation.